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Complaints/Grievances Coordinator-Children's in Latham, NY at Beacon Health Options

Date Posted: 12/7/2018

Job Snapshot

Job Description

ABOUT THE POSITION

We are currently seeking a dynamic Complaint and Grievances Coordinator for our Quality Management Department to join our team at our office in Latham, NY!  The Complaint and Grievances Coordinator will be responsible for c oordinating all levels of member and provider complaints and/or grievances to ensure timeliness and compliance with URAC, NCQA, ERISA, and applicable New York State and other regulatory body regulations. Produce necessary documentation for complaint and grievance decisions. Maintain accurate database entry and reporting functions, including local access database and ServiceConnect inquiry process related to complaint and HIPAA queues.  Assist in identifying, tracking and trending quality improvement opportunities related to complaints and grievances. Work collaboratively with internal Beacon staff, providers, and contractual contacts.   Maintain sound customer relations while researching and gathering complaint and grievance information.  Grievance functions include Medicaid Fair Hearing requests and TDI Complaint Appeal Panel requests.  The Complaint and Grievance Coordinator will support other QM activities including but not limited to:  Designated Record Set (DRS) processing, Privacy Breach documentation and investigation, compliance and assistance with applicable URAC, NCQA, TDI, and contract standards. 

Position Responsibilities:

  1. Perform complaint and grievance functions, including case file set up, complaint notification and resolution letters, database entry, ServiceConnect inquiry related tasks, claims research, and coordinating with providers, members, State contacts, and internal Beacon department staff related to successful resolution of the complaint.
  1. Monitor complaint and grievance turnaround to ensure all elements are completed within the timeframes.  This includes five calendar days to acknowledge and 30 calendar days to resolve category I complaints and maintain compliance with Fair Hearing and Complaint Appeal Panel timeframes. Note: Some client contracts may have stricter periods than the corporate policy.
  1. Produce reports for committees (i.e. QMC and other Region) and external reports to clients and other entities as needed that show trended appeal information.  Assist with monthly Complaint and Grievance Reports to ensure accurate and concise information is provided that meets all entities’ report specifications.
  1. Review complaint information including service issues, internal Beacon systems (MHS, ServiceConnect, CareConnect, FlexCare) and other provider documentation submitted (i.e. treatment records or letters explaining reason for complaint) to assist in making recommendations for complaint resolutions.
  2. Participant in other Quality Management functions such as TDI, URAC, NCQA and Client audit preparation activities and support QM committee functions and Quality Improvement activities as requested. Comply with all HIPAA and other compliance regulations.
  3. On an as needed basis, assist with mail and fax pick-up for the QM department including ensuring mail and faxes are picked up multiple times a day and ensure that any correspondence requests are triaged within the same day or the following day (as soon as possible).
  4. Assist with coverage of the appeals department as needed and directed by supervisor.
  5. Other job duties as assigned.

Position Requirements:

Education : High School Diploma, Bachelor’s Degree Preferred

Relevant Work Experience: Prior experience in managed care or insurance setting. Ability to maintain positive customer relations. 

TO APPLY

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Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled

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